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825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeonggi-do, 13449, Korea

In completing the attached application form, please be advised to:

a. Carefully read your Application Guideline(AG) and Program Information(Pl) prior to completing

the application form;

b. Use a personal computer in completing the form, or handwrite in block letters;

c. Fill in the form in Enqlish;

d. Be sure to fill in everv part of the form;

e. Send the completed form to your country's KOICA Office - or the Embassy of Korea stationed in your

nearest country if the former is not available- together with a copv of vour passport; and

f. Be reminded that your participation may be denied if you fail to provide the required information and

documents comPletelY and on time.

Application Checklist

a. Filled in every item of Applicant Information 2-4

b. Ticked agree/disagree box for Agreement on Collection and Use Personal,

Sensitive, and Unique ldentifying Information5-6

c. Thoroughly read Scholarship Program Guideline and Code of Gonduct 6-9

d. Signed the declaration for terms and conditions I

e. signed and filled in every part of Medical History Questionnaire 10

f. Had an authorized official from your government to complete and sign the

Nomination form11

g Have a copy of passport ready for submission

fhrs ts to certify that t have completed every part of the application form

to apply for the KOICA Scholarship Program'

Date: Applicant's Name: Signature:

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825 Daewangpangyo-r0, Sujeong-gu, Seongnam-si, Gyeonggi-do, 13449, Korea

This form is to be used to apply for the Scholarship Program of the Korea lnternational

Cooperation Agency (KOICA), which is implemented as part of the Official Development

Assistance Program of the Government of Korea. Please complete the application form

and consult with your respective country's KOICA Office - or the Embassy of Korea in

charge of your country, if the former is not available - for further information.

(Photo)

PART 1. APPLICANT INFORMATION (to be completed by the applicant

Program fjtle

Name of DeOlee

Duration from to (DD-MM-YYYY)

Name(as in the passport)

First Name

Middle Name

Family Name

Date of Birth Day Month Year

Sex r Male n Female Airport of Departure

Nationality Religion

Home Address

Gontact Information(l ncluding CountrY Code)

Telephone

Mobile

Fax

E-mail

Emergency ContactName

Telephone

Re!afion

E-mail

EmergencyContact (2)

Name

- ;---;" ----lelepnone

Relation

E-mail

Organization

Employment Duration I from to present (MM-YYYY)

Department

Present Position

Type ofOrganization

Government

lnstltution

Others

n Central r Local

n Public n Private

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825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeonggi-do, l-3449, Korea

Job Description

Describe your main duties. Specify any technical equipment or facilities you work on with

if applicable.

Describe any themes, topics and places of interest you would like to see in the Program

related to your tasks mentioned aforesaid.

Elaborate on organizational setback or challenges that you wish to address through the

Program.

Elaborate on your plans to apply the lessons learned from the Program to yot

organization.

Career Background (Past 5 Years)

Organization Department Position / ResponsibilitiesPeriod (MM-YYYY)

From To

Educational Background (Higher Education)

lnstitution City / Country Field of Study and DegreePeriod (MM-YYYY)

From To

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Previous Attendance to Training Program in Foreign Countries

nYes rNolf yes, please specify as below

Have you previously attended any courses sponsored under programs

of Korea (KOICA) or of other countries?

Training Institute

Native Language :

English

Other Languages @base specify) i

1. Excellent: Refined fluency skills and topic-controlled discussions, debates & presentations. Formulates strategies to deal with various essay

types, including narrative, comparison, cause-effect & argumentative essays.

2. Good: Conversational accuracy & fluency in a wide range of situations: discussions, short preseniations & interviews. Compound complex

sentences. Extended essay formation.

B. Fair: Broader range of language related to expressing opinions, giving advice, making suggestions. Limited compound and comple

sentences & expanded paragraph formation'

4. Basic: Simple conversation level, such as self-introduction, brief question & answer using the present and past tenses.

Any restrictions on food, behavior, or medication due to health or religious reasons?Restriction onFood/Behavior/Medication

n YES

n Others(

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PART 2. TERMS & CONDITIONS

Applicants should read, abide by, and respect the following terms and conditions. Failure to abide by the

followings may result in dismissal from the program and report to applicant's government and ior employer.

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b.

Any information used for identifying individuals that is acquired by KOICA will be stored, used and/or

analyzed only within the scope of KOICA activities, and in accordance with KOICA policy and regulations.

KOICA may provide and disclose the collected information aforesaid to a third party in accordance with

KOICA policy and regulations, with the relevant laws of Korea, or upon the request from the Government of

Korea.

KOICA reserves the right to use all the documents or products produced by parlicipants for the purpose of

the Fellowship Program (e.g. thesis, essay, etc.) including their duplication, translation, distribution, and/or

posting on websites (KOICA website and/or other websites related to Korean ODA).

KOICA takes measures required to prevent leakage, loss, or destruction of acquired information. Should

you wish to inquire further about KOICA's privacy policy and personal information management, please

contact the program manager via the contact information provided in your Program Information (Pl), or

send an email to [email protected].

If you do not approve of the above conditions, you may also refuse to agree. However, please be informed

that there may be limitations to your participation to the KOICA Fellowship Program if you do not agree with

the above conditions.

Agreement on Collection and Use of Personal Information

O KOICA collects and uses the participants' Unique ldentifying Information; and is able to provide

such information for a third party in accordance with KOICA policy and regulations.

- Personal Information Collected : name, date of birth, sex, nationality, contact

information, employment status, career and educational record

- Purpose : implementation and promotion of the KOICA Fellowship Program, identification

of participants, record keeping, supporting KOICA Club activities, and strengthening the

partnership between Korea and Partner Countries

- Retention Period : 3 years for hard copy / permanent preservation for soft copy

@ lf you do not approve our collection and use of your personal information, you may also refuse to

agree. However, you may have limited support from KOICA regarding visa issuance,

immigration management, flight and accommodation arrangement, KOICA Club activities,

insurance and medical service.

n Agree r Disagree

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Agreement on Gollection ànd Use of Sensitive Information

O KOICA collects and uses the participants' Sensitive Information; and is able to provide such

information for a third party in accordance with KOICA policy and regulations.

- Sensitive Information Collected : religion, medical information

- Purpose : implementation and organization of the KOICA Fellowship Program in

consideration of participants' religious characteristics, screening of participants' health

condition to participate in KOICA Fellowship Program, insurance and medical service

- Retention Period : 3 years for hard copy / permanent preservation for soft copy

@ lf you do not approve our collection and use of your sensitive information, you may also refuse

to agree. However, you may have limited support from KOICA regarding your religious activities

and requirements, insurance and medical service.

n Agree ! Disagree

Agreement on Gollection and Use of U,nique ldentifying Information

O KOICA collects and uses the participants' Unique ldentifying Information; and is able to provide

such information for a third party in accordance with KOICA policy and regulations.

- Unique ldentifying Information Collected : passport number, alien registration number

- Purpose : visa issuance, immigration management, flight and accommodation

arrangement, insurance and medical service

- Retention Period : 5 days after the accomplishment of the purpose specified above

lf you do not approve our collection and use of your unique identifying information, you may also

refuse to agree. However, you may have limited support from KOICA regarding visa issuance,

immigration management, flight and accommodation arrangement, insurance and medical

service.

@

n Agree n Disagree

is guideline aims to provide necessary guidance to help to create a sound environment for the study of participants

under the KOICA scholarship program.

2. Definition of Terms

The terms used in this guideline are defined as follows.

2-1. "KO;CA," a Korean organization dedicated to ODA, is in charge of the scholarship program, entrusting itto

universities and providing funding.

2-2. "scholarship program (SP)," one of the Fellowship programs provided by KOICA, refers to a masters degree

program, aiming to nurture key leaders who can contribute to economic and social development of

countries.

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2-3. "University" refers to the university that is entrusted by KOICA to operate and be responsible for the SP'

2-4. "Parlicipants" refer to individuals participating in the SP under the nomination of the governments of partner

countries. Upon enrollment, the participants are entitled to be provided with adequate support as students of the

university, and bear the corresponding responsibilities.

3. Obtaining a Degree

3-1. Participants shall obtain a master's degree at their registered university.

3-2.lf a participant loses his or her status as a KOICA participant in accordance with the guideline 6. "Dismissal of

participant Status", he or she shall automatically lose the qualification as a degree candidate in the university.

. Entering and staying in Korea

-1. In principle, participants are not allowed to accompany their own family members to stay in Korea during SP

duration, except for their family members' temporary visiting or traveling less than a month.

4-2. lt should be noted that only the person whose name appears in the invitation letter sent by KOICA is considered

a program participant. No others will be given any support and amenities when entering and staying in Korea

-3. KOICA shall not be held responsible for any undertakings or consequences arising from the non-compliance of 4-'1

a00ve.

5. Leaving the Korea

5-1. Participants shall leave Korea on the designated day for leaving the country

S-2.lf a participant loses one's status as a KOICA participant pursuant to the guideline 6. "Dismissal of Participant

Status", he or she shall leave Korea within 3 days from the date the dismissal is decided.

5-3. lf a participant has to extend his or her stay in Korea, or leave for a third country other than his or her home

country, due to inevitable circumstances, a written approval from the home government should be submitted to the

KOICA head office through the Korean embassy in the home country'

5-4. Even in the case for the guideline 5-3, the relevant expenses shall be borne by the participant.

. Dismissal of ParticiPant Status

1. participants will lose their status as SP participants if they commit any of the following acts or fall under any of the

situations described below.

@ Falsifying statements on any of their application documents or providing false information in their application

documents.

@Receiving serious disciplinary actions, such as suspension or expulsion from the university

Violating the Korean law

Temporarily leaving Korea for more than once without permission

lnvolved in any political activities

Violation of the agreement with KOICA

@ Failure to follow the decisions made by KOICA regarding the program intentionally

@ Behaving disgracefully as a participant of a SP

@ Withdrawalfrom the program before completion

@ Failing to leave Korea within the given time frame as stated in this guideline 5. Leaving the Country of this guideli

6-2. lf a participant loses one's status as a KOICA SP participant, KOICA will notify the head of the Korean diplomatic

establishment abroad and the government of the participant's home country of the fact.

. Leaving Korea During the Program

-1. lf a participant intends to return to one's home country during the course of the program, due to unavoidable

reasons such as serious illness, domestic affairs, or an urgent summoning from the home government, he or she

must acquire prior approval from the university with the following documents.

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A copy of the medical certificate (for sickness leave)

O Letter of exPlanation

Any other documents required by the university

7-2.lf a participant has to return to one's home country due to one's own fault, and not for any of the reasons listed in

guideline 7-1, KOICA will notify the participant's original place of employment and the home government of the

fact. The participant may not re-apply for any KOICA training programs in the future.

8. Temporary Leaveg-1. lf a participant intends to leave Korea temporarily during the vacation, he or she must obtain approval from the

university with the following documents by the date set by the university.

OLetter of confirmation from the advisor

@A copy of a round triP air ticket

@A copy of traveler insurance (when traveling to a third country)

Any other documents required by the university

g-2. Temporary leave during the semester (including during summer and winter schools and orientation programs) is

not allowed. Exceptions will be made only for inevitable reasons, such as death of family member or a marriage

the participant. Even in these cases, a prior approval must be obtained from the university and KOICA.

. For the days of the temporary leave, daily allowance will be deducted for each day of a leave (including days of

departure and re-entry). And there will be no exception for deduction.

. In case of death of an immediate family member (only for participants'own parents, spouse, and children),

KOICA will support roundtrip airticket for temporary leave.

9. Scholarship Payment and Receipt

9- 1 . The matters regarding tre pa;ment and receipt of scholarship shall be defined by KOICA

9-2. Scholarship may not be given out under the following cases. However, if KOICA acknowledges the inevitable

nature of the matter of the withdrawal from the SP, the participant may receive support for his or her return.

O Failure to leave Korea within the given time frame, for reasons other than inevitable reasons for departure stated in

5-3 of this guideline

@ Dismissal of a KOICA participant status as stated in 6. Dismissal of Participant Status.

@ Withdrawal and leaving Korea during the program for reasons other than stated in 7-1

10. Notification of Re-entry

lf a participant re-enters Korea within the allowed period for a temporary leave, the participant shall report his or

re-entry to the person in charge at the university.

11. Notification of Ghanges in Gontact Information

lf there are any change to the contact information of a participant, the change must be reported immediately to the

{2. Internship12-j. participants must follow the regulations regarding internship, in order to guarantee full commitment to SP and

create a "study-first" environment.

@ Participants must give first priority to their studies over any other activity'

@lnternship activities related to research and academic activities of a participant's area of studies, are allowed upon

approval of the universitY.

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12-2.lf a participant earns more than KRW 20,000 a day from the internship, any exceeding amount will be deducted

from one's dailv allowance.

3. Applicable Provisions

For any other matters not stipulated in this guideline, the academic regulation of the participant's registered university

1. Purpose

The Code of Conduct for participants of the KOICA Scholarship Program (hereafter "Code of Conduct") aims to provide

both ethical and behavioral standards for the participants to ensure the successful completion of the KOIC

Scholarship Program (hearafter "SP").

Application and Gompliance

is Code of Conduct applies to all participants of the KOICA SP.

. Academic Performances

3-1. participants follow the instructions and guidance provided by the professors and faculty of the university that they

have enrolled in (hereafter "university") to facilitate their studies.

3-2. participants faithfully attend their university classes and become fully involved in their studies in accordance with

the regulation and guidelines of the universities.

. In order to ensure appropriate academic achievement, temporary leave or travel to a third country during the

course of the semester is, in principle, not allowed. For temporary leave or travel to a third country during the

summer and winter vacations, a participant must gain approval from the university.

. participants shall not seek employment or commercial activities for personal gains, except for internship progr

approved by the University.

Program Outcome

participants shall return to their organization of origin upon the completion of SP and try to apply knowledge and skill

acquired from SP to contribute to the development and advancement of their home country.

5. Health Management

participants are recommended to make efforts to stay healthy by working out regularly and seeking medical care

ecessary. lf and when Participants experience a deterioration in health that may require care from medi

ionals, they must report such medical issue to the university to get necessary help.

Safety Measures

1. participants must refrain from visiting places that may be dangerous, or getting involved in acts that may cause

safety accidents. For any damages caused by voluntary actions that violate the code of conduct, the participant in

question shall bear full responsibility.

2.lf and when accidents or situations occur that may put participants at risk, SP participants shall immediately

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the matter to the University to seek necessary help. However, if it is found and determined that SP partici

are responsible for the occurrence of the reported accident or situation, whether intentionally or otherwise,

University may take disciplinary actions against SP Participants in accordance with their relevant regulations,

after the resolution of such accident or situation.

. Policy on Misconduct

-'1. Participants shall always behave, act and speak responsibly and honorably, recognizing that their words and

actions represent the University and KOICA as well as the country of their origin.

-2. Participants shall refrain from accessing inappropriate establishments that could impair their dignity.

. Discriminatory Actions and Sexual harassment

-1. Participants shall complete mandatory courses designed to prevent discrimination and sexual harassment

provided by KOICA and the university and shall act accordingly.

8-2. Participants shall not engage in any aggressive or insulting behavior or use of words of discrimination against

gender, religion, disabilities, age, nationality, physical appearance, marital status, family status, ethnicity, politica

ooinion or sexual orientation.

3. Participants shall not engage in any sexual harassment including sexually oriented jokes or innuendos,

unwelcome invitation for outings, unwelcome sexual advances, requests for sexual favors, and other verbal or

physical harassment of a sexual nature.

. Participants shall be cognizant of the fact that sexual harassment herein is defined in accordance with intern

norms and standards. lt is to be noted that sexual harassment shall be judged and determined on the basis of

claims and feelings of victims, not the intent of the behavior.

. Participants shall also acknowledge that both discriminatory actions or sexual harassment shall not only be

regarded as cause for disciplinary actions including dismissalfrom the SP, according to rules and regulations, but

also be subject to legal actions under the Korean law.

. lt is strongly recommended that participants who fall victim of or witness to any act of discrimination or sexual

harassment must immediately report the case to the university and seek assistance.

9. Prohibition of Political Activityparticipants shall not take part in any political activity, such as supporting a certain political group or getting involved in

any political movements.

10. Compliance with the Regulations of the University and KOICA

10-'1. Participants shall fully comply with the academic regulations of the university and guideline of KOICA.

1O-2.lf a participant violates any of the regulation of the university or KOICA, he or she shall be subject to disciplinary

measures, as stipulated in such regulation, can be enforced.

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(name of applicant) (name of country)

ceftify that the statements I made in this form are true and correct to the best of my knowledge.

lf accepted for the program, I agree to respect SP Participant Guideline and Code of Conduct set forth above.

lf lfailto comply the terms and conditions of KOICA Scholarship Program,

lwill accept any penalties and consequences including dismissalfrom the Program

and report to my government and/or employer.

Date: _ Applicant's Name:

11

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PART 3. MEDICAL HISTORY QUESTIONAIRE

1. Present Status

a. Do you currently use any drugs for the treatment of a medical condition? (give name & dosage)

n No lr Yes ), Quantity ( )

b. Are you pregnant? (female onlY)

nNo n Yes months )

c. Please indicate any needs arising from disabilities that may require additional support or facilities.

( )

Note: Disabitity does not lead to dismissal or exclusion from the Program. However, upon the situation, you may

be directly inquirecl by the KOTCA Program Manager for more detailed account of your condition.

2. Medical History

a. Have you had any significant or serious illnesses? (lf hospitalized, give place & dates.)

b. Have you ever been a patient in a mental hospital or have been treated by a psychiatrist?

c. High blood pressure

d. Diabetes (sugar in the urine)

e. What illness(es) have you had previously?

f. Has the above illness(es) been cured?

t certify that t have answerec! all questions truthfutly and completely to the best of my knowledge'

Past: nNo r Yes >> Name of illness ( ), Place & dates ( )

Present: nNo n Yes >> Present condition ( )

Past: rNo : Yes >> Name of illness ( ), Place & dates ( )

Present: rNo : Yes >> Present condition ( )

Past: :No r Yes

Present: rNon Yes >> . Present condition (

. Are you taking any medicine?) mm/Hg to ( ) mm/Hg

nNo nYes

Past: rNo n Yes

Present:rNo r Yes >> . Present condition (

. Are you taking any medicine or insulin?)

n YesrNo

n Thyroid Problem n Liver Disease n Heart Disease I n KidneY Disease

r Tuberculosis n Asthma r Stomach and Intestinal Disorder

r Infectious Disease )

r Others )

I Yes nNo- Specify the name of illness (

- Present condition (

)

)

Date: Applicant's Name: Signature:

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PART 4. NOMINATION

The Government of officiallv nominates(Name of Country) (Full Name of Nominee)

as organized by the Korean Government(KolcA)to participate in(Title of Program)

and l, on behalf of the Government of certify that(Name of Authorized Official) (Name of Country)

(a) AII information including career and educational background quoted by the nominee in this form is true, complete

and accurate to the best of my belief and knowledge.

(b) The nominee has an adequate knowledge of and/or expertise in the training field and has a sufficient proficiency

of the language required, both spoken and written, to undergo the Scholarship Program.

(c) On behalf of the organization I agree to the terms and conditions of KOICA

(d) My organization shall be responsible for dealing with claims by KOICA and third parties where the loss or

damage to their property, or death or personal injury was caused by gross negligence or willful misconduct of the

Nominee during the participation to the KOICA Scholarship Program.

(e) Nominee's unsafisfactory peÉormance or failure to conform to the code of conduct may lead to limitedopportunities for the organization's nomination to the KOICA Fellowship Program.

Name(Authorized Official) :

Position/Title: Organization:

Email:Telephone:

Date: Signature:(Official Stamp I ncluded)

13

Documents

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